DAFNE Follow-Up Course - No Help?

Yesterday I attended a DAFNE follow-up course at my local hospital. I have been to a number of them since I graduated in 2007. However, on this occasion I was able to participate in the Q&A session at the end of the course. I raised a question about how I can use DAFNE principles to achieve good BG levels with a variable routine. To my surprise one of the DAFNE Diabetes Nurses replied, "Sorry I can't answer that question, because DAFNE principles are not designed for variable routines!"

Let me explain my variable routine. I read water meters (Mon-Fri) for a living. That means sometimes I can be walking for up to six hours day. On another occasion I could be walking for three hours and driving for three hours. Also, I could be in a team meeting most of the day, and getting no exercise. If it's the weekend, it changes again, perhaps with some activity Saturday, and a quiet day Sunday.

At the moment, I use a combination of ratios (0.5:1, 0.67:1, 1:1, and 1.5:1) and take into account my previous days exercise, and the activity level I anticipate for the day ahead. However, I often select the wrong ratios because I don't know how my body will react to the previous days exercise or lack of it! There are no consistent patterns with my BGs. Sometimes they're high (13-15), sometimes too tight (3-4).

I know my lifestyle is complex, but I was surprised that no help was forthcoming. So now I'm thinking, what's the point of using DAFNE principles? I'm just doing a guessing game!

Some background info. I have daily injections of Humalog before meals, and Levemir before bed, and before breakfast.

I'd suggest recording your BGLs and CPS, and QA and Basal doses using the BG diary, and then using past history to see what worked and what didn't. This can give some idea of how to adjust for days in the future that are similar to the past. It won't be perfect, as there are always random results, but hopefully it gives some pointers into how to make adjustments.

Warning - writing as a parent of two children with diabetes (diagnosed at 7 and 12, now adults), neither of whom have done DAFNE. Self taught carb counting and insulin dose adjustment 15+ years ago, one currently using an Omnipod pump and Dexcom CGM, the other using MDI.

Further to Warwick's excellent suggestion, could you categorise your days and give them labels to help spot patterns and set ratios for each type? So days where you walk 5-6 hours could be type A, meeting days could be type B, etc. How predictable are your days? Do you know in the morning if you will have a type A or B day, for instance?

Also, does DAFNE include varying basal insulins? After an active day my son will reduce his night time basal insulin, sometimes the following morning too. If insulin resistance has become an issue, he might increase the basal insulin. If you know you are going to have a type A day and walk lots, would you reduce your basal insulin in the morning?

Warwick, what you've suggested is what I'm doing, but as you say it doesn't always work, but it's the best I can do.

Jos2, I've tried varying my basal dose however, if I increase it on a Friday for a quiet weekend for example, there's too long a delay before the BI builds up (2-3 days) by that time it's Monday and I need reduced doses again. Also, I'm quite sensitive to insulin so have low BI doses. (Before breakfast 7.5U and 8U before bed).

I have two boys in their 20s that have type 1 diabetes too, one has a pump and the other a pump and a CGMS. My diabetes nurse said I don't qualify for a pump because my HBA1C isn't high enough.

I do have 33 years of diabetes experience though, of which 10 applying DAFNE principles. I guess I'll have to get my thinking hat on!

Hi, I will feed this back to the DAFNE people, particularly the consultants I'm sure they will be interested in this statement from a DAFNE trained HCP. For me the whole point is that DAFNE does teach you to handle stuff like this and a 'confident' HCP should have been able to help you with this. I think most of us have a varying routine, perhaps NOT as varied as you but its all degrees of the same problem. If we all did no exercise to keep things simple we wouldn't be helping ourselves in the long run would we ;-)

Being old school, I agree with Warwick note everything down and build up a picture. You won't get it right all the time even with this information, sorry that's just life but it will help. One of the main principles of DAFNE is to record stuff and look for patterns, even in a lifestyle like yours and that's what they should have told you including adjusting for exercise. This is probably no help but what helped me a lot is going on a pump, but you need a good consultant for that who will refer you ;-)

Thanks for your comments. Just to clarify, I thought the course was run very well I was just surprised that no help was offered. For example, perhaps if the question was opened up to the audience, someone might have offered a solution.

At the moment I seem to have got to grips with my diabetes control.

On the subject of seeing a consultant, I haven't seen mine for two years. We were told at the start of the course that due to severe staff shortages we won't be seeing him any time soon.

sorry for the delayed reply, I probably passed out with Shock when I read you had not seen a consultant for two years !!! Which hospital are you under in Maidstone ? I live in Ashford just down the road from you and see consultants at two hospitals at the moment ( sorry). ALL T1's should be seen by a consultant ever 12 months and its ridiculous that you are being seen by no one. I don't accept staff shortages as an excuse. Are you a member of Diabetes UK ? I would let them know about this and if you are not a member I will let the know. Their campaigning manager for the South-East wants to come visit my local group soon and this is exactly the kind of issue that they should be campaigning about.

Without sounding a misery guts (I do appreciate that the NHS is overstretched), when I do see the consultant, he'll spend about 10 minutes with me, look at my BG diary, and say something like, "Your diabetes is unstable. Go and see the diabetes nurse to help stabilise it. Come back and see me in six months time."

Unfortunately for me I've been told that my diabetes is not unstable enough to qualify for an insulin pump, so I have to do the best I can with injections.

On a positive note, at least I get a proper check-up at my GPs once a year.

If your DSN team are anything like mine, they expect that if you've done DAFNE then you should be able to suss everything out yourself with minimal follow up care from them (which is a stupid attitude to be frank but that's how it is with my DSN team).